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The Vermont Department of Health Pre-Hospital Documentation Vermont Emergency Medical Services Last updated October 2006.

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Presentation on theme: "The Vermont Department of Health Pre-Hospital Documentation Vermont Emergency Medical Services Last updated October 2006."— Presentation transcript:

1 The Vermont Department of Health Pre-Hospital Documentation Vermont Emergency Medical Services Last updated October 2006

2 The Vermont Department of Health An Actual Run Form Upon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.

3 The Vermont Department of Health An Actual Run Form Upon our arrival, found pt in bed with first responders complaining of breathing difficulty. Pt. physician saw her yesterday. Had cold X 2 weeks. Physician said lungs were congested. Nauseated, no vomiting. Upon listening to lung, equal but noisy. Pt initially put on 4 liters nonrebreather, complained so we used 24% Venturi. Allergic codeine. Dr. Bitlett. Pt diabetic due for insulin 8:00. Meds insulin.

4 The Vermont Department of Health Session Goal  At the end of this session, the student will be able to use the Vermont EMS Incident Report Form to document a pre ‑ hospital call in a systematic and complete fashion.

5 The Vermont Department of Health Learning Objectives At the end of this session, the student will be able to: 1.describe the SOAP or CHART method of charting 2. list at two principles of writing a narrative 3. describe the role of documentation when a patient refuses care or transport 4. describe how care administered to a patient in a multiple casualty incident is documented

6 The Vermont Department of Health Learning Objectives 5. given pieces of information (in random order) about a call, properly document the assessment and treatment of the patient 6. describe the procedure to use when adding or correcting information on the run report form after the copies have been separated 7. (for Advanced EMTs only) list the pieces of information which should be recorded on the run report form when the EMT administers advanced life support in the field.

7 The Vermont Department of Health What This Session Will Cover  Importance & Purposes of Documentation  Frequent Problems (and Solutions)  Completing the VT EMS Incident Report Form  Exceptions and Special Cases  Demonstration and Practice

8 The Vermont Department of Health Purposes of Documentation  educational properly done within HIPAA requirements  administrative statistics and billing  research

9 The Vermont Department of Health Purposes of Documentation  evaluation and critique What proportion of patients with a chief complaint of difficulty breathing receive high concentration oxygen?  continuity of treatment in hospital

10 The Vermont Department of Health Purposes of Documentation  legal form is not evidence in itself becomes evidence as part of testimony of witness to authenticate it can be used to refresh the memory of a witness retain original for legal purposes

11 The Vermont Department of Health Kinds of Errors  incomplete or incorrect blanks and boxes (e.g., date) SOLUTION? have someone else check the form

12 The Vermont Department of Health Kinds of Errors  incomplete or incorrect narrative (e.g., description of a patient's injuries without mentioning that he was in a collision SOLUTION? use an outline to remind yourself what information to include

13 The Vermont Department of Health Kinds of Errors  form reflects incomplete assessment or poor care SOLUTION? document extenuating circumstances  combative patient  language barrier  pt refusal to cooperate  extrication difficulties  delay in response, at the scene, or en route to ED

14 The Vermont Department of Health Kinds of Errors  form reflects incomplete assessment or poor care SOLUTION? if deviation from the usual treatment protocols occurred, explain why; do not try to cover up errors or omissions in care

15 The Vermont Department of Health The Vermont EMS Incident Report Form or Patient Care Report (PCR)

16 The Vermont Department of Health PCR Demographic Info

17 The Vermont Department of Health Code 2/Code 3  Any use of lights OR siren = Code 3

18 The Vermont Department of Health Nature of Call/CC  Fill in the chief complaint or nature of call as found, not as dispatched

19 The Vermont Department of Health Treatment & Vital Signs

20 The Vermont Department of Health Level of Treatment & Transport  Fill in treatment based on what the agency completing the form did for the pt  Fill in transport based on treatment the pt is receiving, regardless of who gives it

21 The Vermont Department of Health

22 Trauma Score  Complete for trauma patients only  Use information from earliest EMS assessment  Let the hospital worry about adding up the numbers

23 The Vermont Department of Health Vital Signs  Repeat VS frequently  Put SpO 2, blood glucose, etc. in comments

24 The Vermont Department of Health Vital Signs  As needed, draw lines to make additional boxes for vital signs

25 The Vermont Department of Health A System for Comments SOAPSOAP

26 The Vermont Department of Health The SOAP System Subjective Objective Assessment Plan

27 The Vermont Department of Health Another System for Comments CHARTCHART

28 The Vermont Department of Health The CHART System Chief complaint History Assessment Rx (treatment) Transport

29 The Vermont Department of Health SOAP  Subjective Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH)

30 The Vermont Department of Health Subjective/History  History of Present Illness (HPI) O P Q R S T U

31 The Vermont Department of Health Subjective/History  History of Present Illness (HPI) Onset Provokes Quality/Quantity Region/Radiates Severity Time Undo + associated symptoms

32 The Vermont Department of Health Subjective/History  Past Medical History (PMH) MA AM IP DL SE

33 The Vermont Department of Health Subjective/History  Past Medical History (PMH) MedicationsAllergies Allergies Medications IllnessesPertinent past history DoctorLast oral intake SurgeryEvents leading to illness or injury

34 The Vermont Department of Health Objective/Assessment – Trauma  pt appearance, position and surroundings  head, eyes, ears, nose, throat  neck  chest  abdomen and pelvis  extremities

35 The Vermont Department of Health Objective/Assessment - Cardiorespiratory  pt appearance, position and surroundings  neck – jugular veins  chest – lung sounds  extremities – pedal edema  other – oxygen saturation, EKG as appropriate

36 The Vermont Department of Health Objective/Assessment – Altered Mental Status  pt appearance, position and surroundings  mental status AVPU orientation memory loss of consciousness

37 The Vermont Department of Health Objective/Assessment – Altered Mental Status  pupils  trauma exam, including movement of extremities  other blood glucose oxygen saturation, EKG as appropriate

38 The Vermont Department of Health Exercise #1  In the first blank for each phrase, indicate what kind of information is given by using Hx for history and PE for physical exam.

39 The Vermont Department of Health Principles of Narrative Comments  Include pertinent negatives. If a pt c/o chest pain, document the presence or absence of.

40 The Vermont Department of Health Principles of Narrative Comments  Include pertinent negatives. If a pt c/o chest pain, document the presence or absence of difficulty breathing.

41 The Vermont Department of Health Principles of Narrative Comments  Include pertinent negatives. If a pt c/o chest pain, document the presence or absence of difficulty breathing. If a pt c/o a blow to the head, document whether or not the pt.

42 The Vermont Department of Health Principles of Narrative Comments  Include pertinent negatives. If a pt c/o chest pain, document the presence or absence of difficulty breathing. If a pt c/o a blow to the head, document whether or not the pt lost consciousness.

43 The Vermont Department of Health Principles of Narrative Comments  Describe, don’t conclude. “A well known, unshaved, unkempt, foul-smelling, slightly cyanotic, 62 y/o alcoholic gentleman was carried into our emergency room by three million lice, all screaming, ‘Please save our host.’” - from an actual doctor’s note shown to a jury in a malpractice suit in 1977

44 The Vermont Department of Health Principles of Narrative Comments  Describe, don’t conclude. Pt had slurred speech, frequent mood swings between happy and combative, inability to walk without assistance and odor of alcoholic beverage on his breath. Is there any need to say this pt was drunk?

45 The Vermont Department of Health Principles of Narrative Comments  Record important observations about the scene. Suicide note found next to pt

46 The Vermont Department of Health Principles of Narrative Comments  Avoid radio codes on the form. Code 11, 33, 55, 77 In the 1970s in some parts of Vermont, this meant: Code 11 = emotional disturbance Code 33 = overdose Code 55 = alcohol intoxication Code 77 = attempted suicide

47 The Vermont Department of Health Principles of Narrative Comments  Use only standard abbreviations. NOT, for instance  CTD (circling the drain)  HIBGIA (had it before, got it again)  FTD (fixing to die)

48 The Vermont Department of Health Principles of Narrative Comments  Include changes in the patient’s condition after treatment or while en route. After 1 tube of oral glucose, pt became lucid and thanked us profusely.

49 The Vermont Department of Health Principles of Narrative Comments  Identify the source of information when it is not the patient. Per wife, pt has used cocaine for 2 years.

50 The Vermont Department of Health Spelling medication names

51 The Vermont Department of Health Spelling orient orientate X

52 The Vermont Department of Health Spelling clavicle clavical X

53 The Vermont Department of Health Spelling dilated dialated X

54 The Vermont Department of Health Spelling crepitus crepidus X

55 The Vermont Department of Health Spelling prostate prostrate X

56 The Vermont Department of Health Spelling palpitation palpation X

57 The Vermont Department of Health Spelling seize seizure (verb) (noun)

58 The Vermont Department of Health Spelling diaphoretic sweaty

59 The Vermont Department of Health Punctuation Who says punctuation doesn’t count?

60 The Vermont Department of Health Punctuation Pt experiences difficulty swallowing tires easily. OR Pt experiences difficulty swallowing, tires easily.

61 The Vermont Department of Health Punctuation She moves her bowels roughly, three times a day. OR She moves her bowels roughly three times a day.

62 The Vermont Department of Health Confidentiality  Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule It’s not just the form that’s confidential, but the medical information about the patient. HIPAA applies whenever your service bills a pt. Even if a pt doesn’t get a bill, the EMS agency and providers are expected to maintain confidentiality.

63 The Vermont Department of Health Exceptions and Special Cases  Multiple Casualty Incidents  Refusal of Care

64 The Vermont Department of Health Multiple Casualty Incidents  Use Met-Tags or local approved equivalent  Standard of care for documentation is different in an MCI

65 The Vermont Department of Health MCI  In an MCI, fill out tag as completely as circumstances allow  Afterward, use tag to complete PCR the best you can

66 The Vermont Department of Health Refusal of Care  Vermont Supplemental Report for Patient Non- Transports to be used with non- transport protocol to be completed in addition to PCR available free from EMS Office

67 The Vermont Department of Health Refusal of Care

68 The Vermont Department of Health Refusal of Care

69 The Vermont Department of Health Refusal of Care

70 The Vermont Department of Health Refusal of Care

71 The Vermont Department of Health Refusal of Care

72 The Vermont Department of Health What About Other VT EMS Forms?  VT EMS no longer collects Cardiac Arrest Report Forms or Esophageal Tracheal Combitube Forms  Follow district medical advisor’s directions  Both forms are available free of charge from VT EMS Office

73 The Vermont Department of Health Learning from Others’ Experience  Evaluate the following narratives and describe how they could be improved.  Note: Information has been typed for ease of reading, but these are actual forms.

74 The Vermont Department of Health Example # 1 Pt has not been feeling well X 1 day. At 4:00 am this date pt started vomiting and uncontrollable bowels. Aching in both arms & shoulders. Pt had a temp. of 39.1 at this time. Pt has taken Datril one at 0116 and again at 0430 this am. No meds. No doctor. No allergies 942 88 98/60 20 1009 124 80/Dopp 17 (20 y/o female)

75 The Vermont Department of Health Example # 1  Strengths? two complete sets of VS en route to hospital  Improvements? disorganized skimpy (what was the chief complaint?) recognize and treat shock when your patient has it

76 The Vermont Department of Health Example # 2 R compound open femur fracture. Lacerations – inner R thigh, R ankle, R toes, R little toe underneath. Abrasions – both elbows, 4 burn marks 1 ½” diameter in thoracic/lumbar region of back. femur fracture w/ bone coming thru medial aspect approx 3” above knee. Open wound approx 3” long lateral aspect approx 2” above knee 1 open wound with great deal of bleeding from medial aspect of wound. Contusions & lacerations to tib/fib area of R leg. Pt. has good motor function of the toes on the R leg and good distal pulse. Pt drowsy and difficult time getting radial pulse. Pt had no guarding in abdomen breath sounds good. NKA, NKM. Pt took off helmet and jacket prior to arrival. 1450 R/L KVO 16 ga LAB

77 The Vermont Department of Health Vital Signs – Example # 2 1427 56 84/P 80 Both legs of MAST inflated 1450 68 104/D

78 The Vermont Department of Health Example # 2  Strengths? detailed descriptions of injuries recognized and treated shock  Improvements? What happened (how was pt injured)? Pre-MAST vital signs? Was initial respiratory rate really 80 per minute?

79 The Vermont Department of Health Example # 3 68 y/o male found lying face down on bedroom floor, had vomited. Pt responsive to verbal stimuli, could answer questions with single words, but could not tell us what happened or speak understandably. Able to move all extremities, oriented to person only. Large contusion L forehead, small abrasion on R forehead and upper bridge of nose. Pupils constricted. Wife reports hx stomach problems but was very upset, unable to give good history.

80 The Vermont Department of Health Example # 3  Strengths? good description of abnormal mental status good explanation for lack of history  Improvements?

81 The Vermont Department of Health Example #4 Arrived to find alert oriented X 3 28 y/o female c/o substernal pain that started approx 4 hrs ago and has been constant. Pain radiated into back. Skin warm, dry & pink. Pain felt as something heavy. Lungs clear & equal bilaterally. Had stress test earlier today – results unknown. Transported with 10 lpm NRB in Fowler’s position. M: Axid. A: N/A. I: Mitral valve prolapse. D: McDonald. S: 1988 Hysterectomy. 2000 108 128/96 24 2018 112 130/P 28

82 The Vermont Department of Health Example # 4  Strengths? good description of history of present illness two complete sets of vital signs  Improvements? nonstandard abbreviations

83 The Vermont Department of Health Correcting Information  Before form submitted: if small error, draw single line through it and initial it agency may require date and time, too if large error, start new PCR  Do NOT try to obliterate error appears EMT was trying to hide something

84 The Vermont Department of Health Correcting Information  After form submitted: if information important, EMT who wrote PCR should use separate piece of paper to:  note reason for addendum and why it was not in original report  note date and time of addendum  describe additional or corrected information Attach to PCR On original form, write “See addendum”

85 The Vermont Department of Health IV Fluids & Medications When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications. IV fluids

86 The Vermont Department of Health IV Fluids & Medications When a slash separates two words in a box, the word to the left of the slash is for IV fluids and the word to the right is for medications. Medications

87 The Vermont Department of Health IV Fluids & Medications Remember to extend the box lines before writing your narrative.

88 The Vermont Department of Health Exercise #2  Work in small groups and organize the information on the cards so that it fits the SOAP or CHART format.

89 The Vermont Department of Health Summary  Have a system for completing the PCR  Have someone else check the form  Beware spelling and punctuation pitfalls  Use non-transport form when appropriate

90 The Vermont Department of Health


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